Dr. Md Rashedul Islam FCPS, MRCP(UK)
Registrar, Neurology, BIRDEM
A 35 years old diabetic right handed lady hailing
from Mirpur, Dhaka got admitted in BIRDEM
General Hospital on 12th November,14
with the complaints of-
• Altered level of consciousness for 12 days
According to the statement of the patient,
she was reasonably well 12 days back. Then she developed altered level of consciousness which was gradual on onset associated with confusion, drowsiness, behavioral changes, difficulty in swallowing & vomiting. It was not associated with fever, headache, loss of consciousness & convulsion.
H/O Present illness
On detailed query she gives history of vomiting for 15 days which was projectile, containing undigested food materials. It was not mixed with blood or bile. It was associated with upper abdominal pain which was burning in nature, mild in severity without any radiation. With the above complaints she was admitted in NIKDU & investigated.
H/O Present illness
CT Scan of brain was done in NIKDU which was normal. Routine blood test was done which showed hyponatremia. She was diagnosed as a case of DMT2 & electrolyte imbalance there & subsequently transferred to Neurology, BIRDEM for further management & treatment.
CT Scan of Brain
H/O past illness: Nothing contributory Socioeconomic history: She belongs to a middle class family
Personal history:
She is non alcoholic, non smoker
Family history:
Nothing significant
Treatment history:
Tab. Metformin
Table salt
I/V 0.9%NaCl during admission in NIKDU
General examination:
Appearance: ill looking, vacant look, NG tube in situ Built: average Decubitus: on choiceAnaemiaJaundiceCyanosisOedemaDehydrationClubbingKoilonychiaLeukonychia
Absent
General examination:
Neck vein: not engorged
Thyroid: not enlarged
Lymph node: not palpable
Skin pigmentation & body hair distribution: normal
Pulse: 86 b/min
BP: 130/80 mmHg
Temp:98 F
RR: 16 breaths/min
• Higher psychic function : Disoriented,
apathetic, decreased responsiveness to external
stimuli. • Speech: Could not be assessed• Cranial nerves : Could not be assessed properly.• Fundus: Normal• GCS: 8/15
NERVOUS SYSTEM EXAMINATION
Muscle Rt. UL Lt. UL Rt. LL Lt. LL
Bulk Normal Normal Normal Normal
Tone Increased Increased
Increased Increased
Power Could not be assessed properly
Involuntary movement
Absent Absent Absent Absent
MOTOR FUNCTION:
Reflex B T S K A Abd Plantar
Right ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑ Absent
Extensor
Left ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑ Abse
nt
Extensor
Sensory system:
Pain Temp Touch Vibration
Position sense
Right upper limb
Could not be assessed properly
Right lower limb
Left upper limb
Left lower limb
• Sign of Meningeal irritation - Absent
• Cerebellar sign : Could not be assessed properly
• Gait: Could not be assessed properly
Systemic examinations
Other systemic examination was normal
A 35 years old diabetic right handed lady got admitted in BIRDEM General hospital with the complaints of altered level of consciousness for 12 days which was gradual on onset associated with confusion, drowsiness, behavioral changes, difficulty in swallowing & vomiting. It was not associated with fever, headache, loss of consciousness & convulsion.
Salient feature
Salient feature
She also gives history of vomiting for 15 days which was projectile, containing undigested food materials. It was not mixed with blood or bile. It was associated with upper abdominal pain which was burning in nature, mild in severity without any radiation.
Salient feature
On examination ,she was ill looking, NG tube in situ Disoriented, apathetic, decreased responsiveness to external stimuli, GCS 8/15, generalized hypertonia, exaggerated deep tendon reflexes including bilateral extensor planter responses. Other systemic examination was normal
PROVISIONAL DIAGNOSIS
• Diabetes Mellitus Type 2
• Pseudo bulbar palsy due to brainstem stroke
• Electrolyte imbalance
DIFFERENTIAL DIAGNOSIS
• Osmotic demyelination syndrome due to Electrolyte imbalance
• Locked in syndrome
• Brainstem encephalitis
Investigations
CBC:
Hb % - 11.2
WBC -7000 cu/mm
Neu-65 %
Lymph- 17.8 %
Mono -5.9 %
Eosino- 1.1%
Platelet- 195000
ESR- 22mm in 1st hour
S. Electrolytes
S. Electrolyte Value Date
S. Sodum 108mmol/l 1.11.14
S. Sodum 129mmol/l 2.11.14
S. Sodum 145mmol/l 5.11.14
S. Sodum 138mmol/l 9.11.14
S. Sodum 139mmol/l 12.11.14
S. Electrolytes
Na-139 mmol/l
K-4.1 mmol/lCl: 108 mmol/lHCO3: 23 mmol/lCa- 8.9 mmol/lMg- 0.8 mmol/lPhosphate-2.8
Lipid profile:
TG: 136 mg/dl
T. Chol : 122 mg/dl
LDL: 55 mg/dl
HDL: 40 mg/dl
LFT:
ALT: 28 iu/L
AST: 32 iu/L
RFT:
S. Creatinine: 0.9mmol/l
S Urea: 36 mmol/l
Sugar - Nil
Albumin – Nil
Ketone- Nil
Epi. cell: A few /HPF
Pus cell: 1-2 /HPF
RBC: Nil
URINE R/M/E
Chest X-Ray
NORMAL
ECG
Normal
MRI of Brain
MRI of Brain
MRI of Brain
MRI of Brain
MRI of Brain
MRI of Brain
MRI of Brain
Endoscopy of upper GIT:
Erosive antral gastritis
Final diagnosis:
• Diabetes mellitus type 2
• Osmotic demyelination syndrome due to hyponatremia
• Erosive antral gastritis
Treatment:
Short acting insulin
Cap. Omeprazole
Neurorehabilitation
Supportive treatment
Patient was counseled about Course and prognosis of the disease
Follow UP
Patient was advised to follow up in Neurology OPD for further clinical evaluation & management
Acknowledgement :
Department of Physical Medicine